Postpartum Haemorrhage in a Woman with Pre-eclampsia

Working diagnosis: primary postpartum haemorrhage from uterine atony, in a woman with pre-eclampsia and thrombocytopenia.

Next drugs (in this order):

1. Oxytocin infusion - 40 IU in 500 mL of isotonic crystalloid over 4 hours (after the initial bolus already given). It is the first-line agent and remains safe in hypertension.
2. Misoprostol 800 micrograms sublingually (or 600 micrograms orally) - a prostaglandin E1 analogue, no hypertensive effect, but expect shivering and pyrexia.
3. Carboprost (15-methyl PGF2 alpha) 250 micrograms intramuscularly, repeatable every 15 minutes to a maximum of 2 mg - reserve for failure of the above; it is contraindicated in asthma and can cause bronchospasm, so ask about asthma before giving it.

Contraindicated drug: methylergometrine (ergometrine).

• Ergometrine is an ergot alkaloid that acts on alpha-adrenergic and serotonergic receptors and produces generalised vasoconstriction; in a woman with pre-eclampsia it can precipitate a hypertensive crisis, seizure, and intracranial haemorrhage.
• It also causes nausea and vomiting, which is unhelpful in a patient who may need anaesthesia.
• The fact that her BP has settled to 138/88 after delivery does not make ergometrine safe - pre-eclampsia remains the diagnosis, and a single bolus can still spike the pressure.

Trap to avoid: reaching for ergometrine because "it is a first-line uterotonic" - it is first-line only in normotensive women.

Immediate non-drug actions in the first 10 minutes:

1. Call for help - obstetrician, anaesthetist, haematologist, blood bank; designate a team leader and a scribe who records time-stamped blood loss.
2. Bimanual uterine compression and uterine massage - the fastest mechanical measure while drugs are drawn up. Also catheterise: a full bladder prevents uterine contraction.
3. Two large-bore (14–16 G) cannulae, warmed crystalloid, keep her warm, oxygen by mask, head-down if she becomes hypotensive. Monitor pulse, BP, urine output hourly.
4. Inspect the genital tract and the placenta - the placenta looks complete, but check for a missing cotyledon and for vaginal/cervical lacerations; a laceration will not respond to uterotonics.
5. Send full blood count, coagulation profile, fibrinogen, renal and liver function, and activate the massive haemorrhage protocol on standby rather than waiting for a further 500 mL loss.

Tranexamic acid:

• 1 g intravenously over 10 minutes, started as soon as PPH is diagnosed and ideally within 3 hours of birth (WOMAN trial evidence).
• A second 1 g dose can be given if bleeding continues after 30 minutes or restarts within 24 hours.
• Do not delay transfer or other definitive treatment to give it; the benefit falls away after 3 hours.

Judgement point: in pre-eclampsia with a platelet count of 96,000, anticipate disseminated intravascular coagulation - the combination of hypertension, thrombocytopenia and haemorrhage is a set-up for it, so fibrinogen and platelet counts must be tracked, not just haemoglobin.

Monitoring:

• Serial platelet counts and coagulation screen (PT, aPTT, fibrinogen) every 2–4 hours; a falling platelet count with a rising PT and low fibrinogen indicates DIC. Pre-eclampsia with thrombocytopenia below 100,000 plus major haemorrhage is high risk for it.
• Watch for haemolysis, elevated liver enzymes and low platelets (HELLP) - check LDH, peripheral smear, and repeat liver enzymes; right upper quadrant pain would be a red flag for hepatic haematoma.
• Hourly urine output (insert catheter), lactate, and clinical assessment of perfusion; keep the blood pressure controlled but avoid dropping it into the uteroplacental range.
• Transfuse to targets rather than to a haemoglobin figure: platelets if <50,000 with ongoing bleeding, fresh frozen plasma and cryoprecipitate for fibrinogen <1.5–2 g/L.

Escalation to theatre - do not wait for collapse:

• Ongoing bleeding despite oxytocin infusion, misoprostol and carboprost plus bimanual compression, or
• Estimated loss approaching 1500 mL or ongoing loss >200 mL/hour, or
• Signs of shock (tachycardia despite fluids, rising lactate, falling urine output), or
• Suspected retained placenta - manual removal under anaesthesia.

Sequence in theatre: examination under anaesthesia and evacuation of retained products, then intrauterine balloon tamponade (or vacuum device), then laparotomy with B-Lynch compression suture or stepwise uterine devascularisation, and hysterectomy as the last resort. A balloon tamponade is the correct next step here, not hysterectomy - she is young, the uterus is atonic rather than ruptured, and the bleeding is not yet uncontrolled.